Quality Nursing Care Celebrates Diversity

Abstract

At the beginning of the 21st century, the familiar biomedical health care "culture" must accommodate not only persons from diverse cultures, but also diverse systems of care. For perhaps the first time in over a century, biomedicine must accommodate others rather than require them to assimilate into its "culture." This fundamental shift requires nurses to move quickly to develop cultural competency as individuals and to provide leadership for this system-wide change. Such competence is important when using complementary and alternative modalities. This article addresses America’s experience with diversity and its legacy in today’s health indicators; it explores cultural competency and its achievement at the individual and system levels; and it discusses the use of complementary and alternative treatments that are a part of this health care "revolution." Nurses are challenged to shape this reform as did the founder of modern nursing 150 years ago.

Nurses currently work within health care systems that reflect biomedical philosophy and practices. These systems serve an increasing number of diverse cultures that have their own health beliefs, values and practices. These may conflict with those of Western medicine. The challenge for the nurse is to become knowledgeable about diverse cultures and to bring about greater cultural sensitivity and competency while working within the health care system. Nurses can be crucial players in bringing about change at the health care system level. System change will take time, persistence and patience, but cultural competence at the system level will result in improved health outcomes and greater satisfaction for patients and providers (Walker, 1996). Understanding cultural diversity will also lead to a greater acceptability of health care practices by other providers.

This article seeks to describe cultural competency and considers pathways to its achievement. The article is divided into three sections: the first section is a brief review of how diversity has been treated in America; the second section focuses on cultural competence in nursing and suggests ways in which it can be achieved by individuals and systems; and the third section focuses on the challenges of using complementary and alternative practices within diverse groups as well as in the American mainstream.

Diversity in America

Cultural diversity has been an integral part of life in the United States since its beginning, "Dating from well before the War of Independence, American culture was born in the crucible of many ethnic traditions: a plethora of Native American tribes, settlers from several European nations and people from various West African kingdoms" (Lavizzo-Mourey & Mackenzie, 1995, p.228). Scientific thought acknowledges that diversity promotes health in all life forms. The more diverse the garden or the forest the more resilient it is. If this is true of other life forms, should it not be true of people as well?

Our nation's history reveals various and divergent approaches to handling cultural differences ranging from destructive (genocide) to competent (DeLoria, 1988). Racism, a destructive approach, has had devastating consequences for Native and African Americans. Racism's legacy is seen in the health status of these groups. For example, in the 19th and early 20th centuries, Native peoples' cultures were destroyed, justified by the European American's theory of Manifest Destiny. Their populations were reduced from an estimated 20 million in the early 15th century to between one and two million today. Native Americans were not given U.S. citizenship until 1924 (Russell, 1993). Although treaties with the U.S. Government established health care for Native people as a right in perpetuity for ceding their land (Deloria, 1988), their health statistics remain the worst of any minority in the United States (U.S. Department of Health and Human Services, 1996).

Consider also the issue of slavery of African American people and its legal legacy in Jim Crow laws in the states that were part of the Confederacy, and the more subtle yet nonetheless separate racial societies of the North. The policy of separation of the races until the middle of the 20th century meant that African Americans did not participate in the benefits other Americans enjoyed. At times they were exploited. As a group, African Americans had no legal right to health care as did Native American people. Today, the infant mortality rate (IMR) for African Americans is twice that for all races (Healthy People 2010, 1998). IMR is an important indicator of need and is considered one of the most sensitive health indicators of how a country cares for its vulnerable populations.

While Native Americans and African Americans were separated from the majority population, waves of immigrants from Europe in the late 19th and early 20th century were expected to blend into the American "melting pot." The newly arrived parents believed that assimilation into the new culture was best for their children and learning English was key. Elders from these groups, however, sometimes express regret that they did not learn their parents' native language.

Likewise, Native American children were schooled in the ways of the white man in boarding schools that disallowed use of their native languages. A Native American man in his early 50s recently shared how he had been punished for speaking to another child in Lakota when this child couldn't understand the English-speaking teacher. At age six and a 100 miles from home, he fled, only to be caught and punished.

The persistent separation of the races is illustrated by the treatment of Navajo "code talkers" who were instrumental in winning World War II because their language could not be decoded by the enemy. They returned to their reservations, but could not legally practice their religion. Freedom of religion became a reality for Native Americans in 1978, under the Carter Administration, 202 years after the Declaration of Independence (Russell, 1993).

The Civil Rights movement in the 1950s and 1960s brought with it increasing pride in one's cultural background. The "melting pot" started to give way to the concept of a mosaic. Cultural differences could form patterns or mosaics. In the 1970s, millions of Americans sat transfixed for several nights watching the television series Roots that chronicled the life of an African American family in the U.S., from their ancestor's capture in West Africa to the present.

New waves of immigrants, following the wars in Southeast Asia, were encouraged to preserve their culture as they learned the language and customs of their adopted homeland. Some health care systems, for example, began working with Hmong clan members, including shamans to provide culturally sensitive care to their community members. Some of these attempts to welcome and respect the Hmong has eased their adjustment into life in the United States and has led to improved health outcomes (Walker, 1996).

Thus, as the 21st century begins, the nation is rapidly becoming multicultural. Perhaps we are dealing with diversity issues more sensitively than at the beginning of the last century. The challenges, however, continue to be very great for new arrivals in this country (Ohmans, Garrett, Treichel, 1996).

Cultural Competence

A country's or nation's dominant culture shapes the way a system of health care is developed and maintained. A nation's unique political, economic, and social cultural factors are reflected in the delivery of health care services. Allopathic or biomedicine has held a dominant position in American health care for over 100 years. There have been and continue to be stunning achievements in surgery, infection control and treatment for physical trauma; however, progress with chronic illnesses has been less impressive.

There is no uniform definition of what constitutes medicine, for it "...has a culture of its own with traditional codes of conduct that have been passed on from generation to generation... it often supercedes the individual culture of the health care provider" (American College of Obstetricians and Gynecologists [ACOG], 1998, p. 2). In recent years holistic systems of care are gaining greater attention. Eisenberg et al. (1998), found that Americans were using complementary or alternative medicine (CAM) at an astonishing rate, considering they were paying out-of-pocket for it. They began turning to CAM to deal with chronic pain, other symptoms, and to aid in lifestyle changes. They were also turning to meditation and prayer in record numbers. The prevalent assumption that biomedicine is superior to all other types of health care can no longer be supported when millions of Americans regularly use and prefer other modalities. Biomedicine is only one system among many and being open to other cultures and their health practices is imperative.

These trends - increasing cultural diversity and increasing use of CAM and spiritual practices - make it necessary for nurses to have a working knowledge of other systems of care as well as the diverse peoples they serve in our current health care system.

Culture can be defined as a shared system of beliefs, values and behavioral expectations that provide social structure for daily living. Cultural values define roles and human interactions within families and communities and with others (Spector, 2000). Culture is taught by precept and example from birth. It is so familiar that one is unaware of its presence and yet it affects all aspects of one's daily life. Interactions with individuals from other cultures are opportunities to reflect on one's own culture. "One of the great values of learning to deal compassionately with those whose cultural backgrounds are very different from our own is what it teaches us about ourselves." (Hufford, 1995, p. 94). Culture determines values and behaviors, but other factors within a culture influence behavior patterns and habits as well. These include a person's age, gender, education, occupation, residence, level of acculturation, social class, life experiences, individually held beliefs, and practices including religious (Luckmann, 1999).

Cultural shock occurs when the differences are overwhelming to individuals and communities. Reactions to other cultures range from fear to celebration. Lack of awareness that a person from a diverse background may have values and health practices that differ from biomedicine's may come as a surprise to some. When this lack of awareness is compounded by an assumption of superiority (racism), serious problems for both patients and providers can result. "Attitudes toward Western medicine constitute one of the biggest barriers to transcultural communication between American nurses and patients. Indeed many nurses feel that the biomedical system is the best (and even the only) approach to patient care. ..T(t)hey may view other health belief systems with suspicion and even contempt, refusing to acknowledge that another's approach might have some merit" (Luckmann, 1999, p. 69). The book, The Spirit Catches You and YouFall Down (Fadiman, 1997), documents the failure of care to a Hmong child and her family while surrounded by available health resources. Even the most well-meaning professionals can fail to provide good care when cultural differences are handled incompetently. It is also important to note that the legal system in America guarantees self-determination. The failure to respect a patient's wishes can lead to legal ramifications (e.g., lack of informed consent, assault, battery, etc.).

Cultural competence is about delivering care while attending to the total situation for the patient and family. A culturally competent nurse will possess a knowledge base, skills and abilities to provide health care to diverse groups and to achieve high levels of patient and community satisfaction among diverse cultural groups. Cultural competence does not require the nurse to be an expert on other cultures or social groups. Instead, it requires sensitivity to diverse cultures by demonstrating cultural awareness, knowledge and respect. Awareness begins with acknowledging that health care has its own deeply held beliefs and practices (Leonard & Plotnikoff, 2000). These are so familiar they can be out of consciousness until they are challenged by a person or community. The author's experience with Native American women suggests that women at menopause are traditionally valued for their increased intuitive wisdom, enjoying a high status within their communities. Contrast the Native American perspective on menopause with that of the dominant culture's view that postmenopausal women are deficient and in need of treatment. How would a women's health provider deal with hormone replacement therapy (HRT) with a traditional Native American woman? Sensitivity to the possibility that HRT might be rejected for cultural reasons could open discussion and promote understanding between the nurse and the patient. It has been said that "(W)hen conflicts occur, culture is likely to prevail" (ACOG, 1998, p. 1).

Awareness of barriers to transcultural communication is an essential component of the knowledge necessary to providing culturally competent health care. Luckmann lists eight major barriers on the part of nurses (Luckmann, 1999). These include lack of knowledge, fear and disgust, racism, bias and ethnocentrism, stereotyping, ritualistic behavior (nursing rituals in patient care), language barriers, and differences in perceptions and expectations. Ohmans, Garret, and Treichel (1996) studied a wide range of providers of care, including nurses, to immigrants in the Midwest. The major cultural barriers to care identified by these providers were: gender, class, age, systems difference, mistrust of health care institutions, non-recognition of medical need by patient or provider, lack of acknowledgment of family systems, the patient perceived as alien or distant, and stigma and shame over a particular condition. The nurse must have a working knowledge of cultural barriers in order to help alleviate them. Perhaps, even more importantly, the nurse must be willing to look at herself in relationship to each of these barriers and modify her behavior if necessary.

How does a nurse achieve the requisite knowledge, skills and respect for differences that lead to cultural competence? The first step is awareness and an honest exploration of one's own cultural values, beliefs and prejudices against other cultures. Humility and self-understanding come first before the study of another culture. "Cultural humility incorporates a life-long commitment to self-evaluation and self-critique, to redressing power imbalances...and to developing mutually beneficial and non paternalistic clinical advocacy partnerships with communities on behalf of individuals and populations" (Tervalon & Murray-Garcia, 1998, p. 117). Self-awareness must not only be intellectual, it must be emotional or heart-felt to be effective (Leonard & Plotnikoff, 2000).

Once the nurse acknowledges the need to learn about diverse people, researching a group frequently served might provide ease of access. If the nurse serves a Hmong population, for example, reading books, watching video tapes and searching the Internet would constitute a first step in the learning process. Hmong community leaders may be open to presenting information about their culture through storytelling, sharing handiwork, pictures and food. They may be able to suggest exhibits, cultural displays and activities that would give additional knowledge and insight into their lives and culture. When genuine interest in their culture is demonstrated, the good will that may be generated may facilitate better relationships in time. As trust is built, health outcomes may also improve. Once people from another culture know that they are respected and their health care providers are trying to learn how to care for them, they will be much more likely to share their health concerns. Better treatment should result in better health outcomes (See Figure 1). The author worked with a young Hmong mother whose toddler required surgery to repair a patent ductus arteriosus. With a working knowledge of the Hmong culture, the nurse encouraged the mother to share her fears and plans for her daughter. Although the Hmong traditionally oppose any surgery, this young mother, while respectful of her male elders' beliefs and statuses, decided with her own mother to authorize the child's surgery. The surgery was successful and the family was happy with the outcome. The nurse had helped to facilitate communication among the family members and with other providers in the health care system.

In this age of information, nurses have easy access to information that will give them a basic understanding of other cultures. Detailed information about specific cultures and religions can be found on the Internet and in texts. The Web site, Science and Spirit Resources (www.science-spirit.com), exists to promote understanding, enlightenment and exploration of relationships between issues of science and spirituality. The American Academy of Religion (AAR), (www.AAR-site.org) also provides information and research papers for ongoing reflection upon and understanding of religious traditions, issues, questions and values. The National Institute for Healthcare Research's (NIHR) Web site (www.nihr.org) serves as a major source of information and communication in religion and human health and wellness. It also has a substantial listing of books and book chapters from 1995 forward, research summaries, and research methods. They also have an education section that gives current research reports and media fact sheets. The Spirituality and Health's Web site (www.spiritualityhealth.com) lists over 15,000 reviews of current books, audiotapes, films and videotapes.

General knowledge of another culture is necessary but not sufficient. Assessment and communication skills are also important. Lipson (1996) offers a cultural assessment framework that provides key areas for gaining information. A comprehensive assessment should include the following components: birth place, time since immigration if appropriate, ethnic affiliation and its strength, primary and secondary languages, speaking and reading ability, people (family members and friends) who support them, religion and its importance in daily life and current practices, food preferences and prohibitions, health and illness beliefs and practices as well as customs around such transitions as birth, illness and death.

Detailed knowledge of another's culture and faith tradition combined with the nurse's self-awareness is fundamental to cultural communication competence. These are further enhanced by the nurse's development of communication skills that bridge cultural differences. The skills encompass conveying empathy and showing respect by conducting one's self in a way that is sensitive to the person's cultural background and preferences. This might require the nurse to be more formal with persons from some cultures. Asking how they wish to be addressed conveys respect. Using first names can be offensive to elders even though it is common among younger persons from the same cultural group. Taking time to establish such basic interactions will build rapport and trust in the nurse-patient relationship. Active listening is essential, as well as is providing feedback to the patient and family.

Luckmann (1999) discusses specific transculture communication techniques. These are basic communication skills with the added dimension of increased sensitivity to allowing for silences, creating opportunities for the patient to ask questions, providing sufficient time for an interaction, and lastly, not appearing in a hurry or rushed.

Nurses working with persons who speak another language must work through interpreters. Learning to work with an interpreter is a crucial communication skill. Luckmann (1999) provides detailed information on this critical communication skill. The most fundamental requirement is a qualified interpreter who can truly aid communication rather than distort or get in the way of it. In addition to the ability to speak another language and English, the interpreter needs to know the role, his or her personal limitations, and the responsibilities of an interpreter. The nurse should not use children or other relatives and friends for interpretation unless an interpreter is unavailable. Also, the nurse should speak directly to the patient by remaining focused on the patient rather than the interpreter. The nurse should speak slowly and keep the communication free of technical language and jargon. Pre and post meetings with interpreters are highly recommended.

Health care systems must also strive for cultural competence as well as individual nurses and other health care providers. A culturally competent system..."values diversity, has the capacity for cultural self-assessment, is conscious of the dynamics inherent in any multicultural encounter, and has developed the necessary adaptations to service delivery that reflect an understanding and appreciation of cultural diversity" (ACOG, 1998, p. 4). Cultural competency is an evolving process for systems and individuals alike. Cross, Bazron, Dennis, & Isaacs (1989) conceptualize six steps to system-wide cultural proficiency. The lowest level is cultural destructiveness. This is followed by cultural incapacity, a step above destructiveness, but still lacking in capacity to effectively respond to diverse groups. Cultural blindness is seen in an organization that operates under the pretense that culture, race, and ethnicity do not make a difference. Precompetence is the organization's recognition of their weaknesses and a desire to change it. Cultural competence is demonstrated in genuine acceptance and respect for cultural differences and a clear understanding of these differences. Cultural proficiency is seen in organizations that hold culture in high esteem because it is integral to them.

Since systems greatly influence the behavior of individuals, it is imperative for nurses to work with systems to promote cultural competence. The National Center for Cultural Competence (NCCC) provides a comprehensive checklist for the development of cultural competence within organizations. The Web site for NCCC is http://gucdc.georgetown.edu/nccc/ncccabout.html. Cultural competence is an important factor in providing effective CAM modalities.

The Use of Complementary and Alternative Health Care Practices

The increase in cultural diversity in the United States today is reflected in an increase in diversity in health care practices, both among persons from diverse cultures, and among the general population (Eisenberg et al., 1998). Complementary and alternative medicine (CAM) is used by many different people including affluent Americans and those from diverse backgrounds. Some of the latter may be native to this country, while others are newly arrived. Irrespective of their backgrounds, the extensive use of CAM modalities among a plethora of peoples presents an enormous challenge to nurses. Cultural competence is needed in using these modalities. However, the use of CAM may not sort out along cultural lines as one might expect. For example, a Navaho medicine man chosen to teach his traditional medicine to Native American medical students was himself a user of biomedicine; he was on kidney dialysis. The medical students he taught were for the most part unfamiliar with traditional healing practices among their own tribal groups. Their ethnic background gave no hint of their health beliefs and practices. The nurse can not assume another's health practices on the basis of cultural background alone; the nurse needs to ask for their preferences and practices.

Each person and family must be treated individually to determine their use of CAM modalities. Using the cultural assessment framework described earlier, the nurse can gain a comprehensive picture of a patient's background including the use of CAM. During a health history, the nurse should inquire about health beliefs and practices inclusive of the use of herbs or medicines the individual takes to alleviate symptoms. Biomedical as well as traditional ethnic healing beliefs and practices may be combined. The nurse should also ask about other providers a patient may have seen regarding a health problem and what these providers have suggested. By being open about other providers, the patient and family may be forthcoming with the information. Their responses may be conditioned, however, by experience with providers who were closed, dismissed, or even condemned other practices. When a patient senses genuine openness to other health care practices and providers, the greater the chances the health of the patient will improve. A grandmother with serious complications from diabetes was willing to drive three hours round-trip from her pueblo and to wait an additional two to three hours to see "her" doctor, a gynecological resident who formed a relationship with her by showing respect for her traditional ways. Her wound that had resisted treatment closed successfully with the combined use of CAM and biomedicine.

Awareness of the use of CAM and routinely asking about its use is an essential step in working with patients and families from diverse backgrounds. Determining, however, the compatibility of herbs with biomedical treatments is also critical. Nurses need to become familiar with the practices used by their patients. The Internet can be a ready resource for this purpose. Two Web sites may be particularly helpful to gaining information about CAM modalities as well as systems of care. The first is The National Center for Complementary and Alternative Medicine (NCCAM) (www.nccam.nih.gov) that is part of the National Institutes of Health. It was established to research and evaluate complementary and alternative therapies in order to determine their effectiveness and safety and to communicate this information to the public and the health care community. This extensive Web site contains information about CAM. The second, The Continuum Center for Health and Healing (www.healthandhealingny.org), is an initiative of Beth Israel Medical Center in New York City. It is an academic integrative medical center encompassing clinical practice, professional and patient education, and clinical research. A significant aspect of the Center's mission is to be a resource for high-level information in the field of integrative medicine, nationally and internationally. Three Web sites for herbal information are: www.ag.uiuc.edu/~ffh/napra.html, www.inpr.org, and www.anmp.org.

Armed with knowledge about specific CAM modalities used by a patient, the nurse has the ability to determine their compatibility with biomedical therapies the patient may be using concurrently. For example, a woman undergoing treatment for cancer of the pharynx used acupuncture and a homeopathic cream on her throat. Midway through the series of radiation treatments, the experienced technicians questioned their dosage calculations because of the excellent condition of her skin. No one had asked her what other treatments she was using. Unfortunately, this lack of awareness is fairly typical of biomedically-based practitioners. The author was privileged to hear an elderly, Ojibwe woman's story about her treatment for gangrene. She followed the Indian Health Service doctor's treatment advice for over nine months in an urban hospital 125 miles from her home. When improvement did not come, her doctors suggested amputation of her foot. Her husband took her back to the reservation to try traditional medicine. A medicine woman treated her with boiled bark she had gathered in northern Minnesota. No amputation was needed. The woman continued to treat her diabetes with insulin and diet. She was willing to combine CAM and biomedicine, but the doctors were not. She went along with them until she was face-to-face with amputation. Months of suffering and expense may have been avoided by combining traditional ways with biomedicine.

Health care is changing rapidly with escalating technology accompanied by soaring costs. American people from multiple cultures are choosing CAM in ever-increasing numbers. These facts make it critical for nurses to become knowledgeable about CAM and diverse cultures. Nurses have always risen to meet the demands of an ever-evolving health care system. Current challenges, however, demand changing one's perspective on biomedicine. "American nurses tend to be heavily biased toward the Western biomedical health care system because most have been educated in it" (Luckmann, 1999, p.69). Changing one's perspective does not mean jettisoning biomedicine. It means broadening one's viewpoint to accommodate other systems and their practices while being cognizant that biomedicine is one among many health care systems in the world. For most of the 20th century, those with other views were expected to assimilate into biomedicine. Today, biomedicine is being asked to accommodate. The process appears parallel to America's change from the "melting pot" (assimilation) philosophy to "mosaic" (accommodation). A nurse initiated sweeping health reforms in Western medicine in the 19th century. Nurses can also choose to provide the architecture for the reforms of the 21st century.

Nurses have a tradition of serving immigrant communities. At the beginning of the 20th century, public health nurses worked with immigrant women and children in the slums of New York City and Chicago. Their work lead to health reforms and government programs that reduced both infant and maternal mortality. The 21st century immigrants need health advocates as much as those who arrived at the beginning of the 20th century. These newcomers are no longer arriving predominantly from European countries. They are influenced by different perceptions of health care delivery, worldview and culture. Nurses who can bridge these cultural gaps will provide not only excellent health care but will have the opportunity to incorporate new ways of treatment and prevention of disease into their practices. Additionally, nurses should seek funding to research new health care delivery models within hospitals and in the community. Working with diverse communities to protect, maintain and enhance their health would have the potential not only to prevent illness but also to serve as a sound investment in both human and economic resources.

The increased use of CAM by the American public is an opportunity for nurses to inform Americans about what the nursing profession offers. Nursing itself can be conceived of as an alternative approach to biomedicine. Nursing's roots are in holism and health. Nurses know that their care fosters the patient's inherent capacity to restore health. The body "knows" how to heal. Nurses know how to support the body's innate ability to heal and maintain health. Many of the CAM traditions are holistic with natural practices that are designed to prevent illness as well as restore health. Nutrition, exercise, and spiritual healing are but some of these modalities common to both CAM and nursing. Nurses need to look carefully at the potential for inclusion of CAM in their practices and to develop their ability to provide culturally competent care in offering these modalities. Research on the use of CAM, its efficacy and safety must be studied. The American public is using CAM without the benefit of solid research, knowledge of efficacy or safety. Nursing can be a force to clarify these practices.

This is a difficult time for the nursing profession due to the deepening nurse workforce shortage that impacts patient care, nursing education and research. The seriousness of the shortage may allow for innovations that might not be possible in less challenging times. Nursing leadership is needed to encourage innovation and experimentation with nursing practice, educational models and research. New partnerships will be needed for this important work. Indeed, nursing is at another significant crossroad in a dynamic time. If history is a predictor of outcomes, nursing will rise to meet these challenges.

Author

Barbara J. Leonard, PhD, RN, PNP is an Associate Professor and Division Head in the School of Nursing (SON) where she provides leadership in Complementary and Alternative Medicine (CAM) curricular integration. Dr. Leonard holds a Ph.D. in hospital and health care administration, a BS degree in nursing and an MS degree in public health. She is also a certified spiritual director with 10 years of experience. Within the Center for Spirituality and Healing, she serves as the director of graduate studies for the minor in complementary therapies and healing practices and also teaches courses on cultural diversity and lectures on spirituality. Dr. Leonard directs a Maternal and Child Health Bureau (MCHB) funded project grant for the preparation of nursing leaders at the graduate level. She holds a professorship in the SON in Long Term Care of Children and Youth.